Preparing for a Doctor Appointment

Many physicians office now have generalized check list for first or follow-up appointments. I HIGHLY suggest you fill this one out before your appointment and take it with you. It is far more complete and you really want to “think” about it before your appointment. The doc is far more likely to pay attention to this list than one you fill in in the office which is often scored by his assistant and he doesn’t really see or pay attention to at the time of the appointment following instead a “practice protocol”

Please indicate on a scale of 1 to 10 the severity and frequency of each symptom, with 10 being the most severe and frequent. Use the past two months as a general guide. If you do not have the symptom, leave the space blank. (Thanks to Dr. Berne for providing this list.)


____________________Fatigue, worsened by physical exertion or stress

____________________Activity level decreased to less than 50% of pre-illness activity level

____________________Recurrent flu-like illness

____________________Sore throat


____________________Tender or swollen lymph nodes (glands), especially in neck & underarms

____________________Shortness of breath with little or no exertion

____________________Frequent sighing

____________________Tremor or trembling

____________________Severe nasal allergies (new or worsened)


____________________Night sweats

____________________Low-grade fevers

____________________Feeling cold often

____________________Feeling hot often

____________________Cold extremities (hands and feet)

____________________Low body temperature (below 97.6)

____________________Low blood pressure (below 110/70)

____________________Heart palpitations

____________________Dryness of eyes and/or mouth

____________________Increased thirst

____________________Symptoms worsened by temperature changes

____________________Symptoms worsened by air travel

____________________Symptoms worsened by stress



____________________Tender points or trigger points

____________________Muscle pain

____________________Muscle twitching

____________________Muscle weakness

____________________Severe weakness of an arm or leg

____________________Full or partial paralysis of an arm or leg

____________________Joint pain

____________________TMJ syndrome

____________________Chest pain


____________________Eye pain

____________________Changes in visual acuity (frequent changes in ability to see well)

____________________Difficulty with accommodation (switching focus from one thing to another)

____________________Blind spots in vision


____________________Sensitivities to medications (unable to tolerate a “normal” dosage)

____________________Sensitivities to odors (e.g., cleaning products, exhaust fumes, colognes, hair sprays)

____________________Sensitivities to foods

____________________Alcohol intolerance

____________________Alteration of taste, smell, and/or hearing


____________________Frequent urination

____________________Painful urination or bladder pain

____________________Prostate pain



____________________Worsening of premenstrual syndrome (PMS)

____________________Decreased libido (sex drive)


____________________Stomach ache; abdominal cramps



____________________Esophageal reflux (heartburn)

____________________Frequent diarrhea

____________________Frequent constipation

____________________Bloating; intestinal gas

____________________Decreased appetite

____________________Increased appetite

____________________Food cravings

____________________Weight gain ( _ lbs)

____________________Weight loss ( _ lbs)


____________________Lightheadedness; feeling”spaced out”

____________________Inability to think clearly (“brain fog”)


____________________Seizure-like episodes

____________________Syncope (fainting) or blackouts

____________________Sensation that you might faint

____________________Vertigo or dizziness

____________________Numbness or tingling sensations

____________________Tinnitus (ringing in one or both ears)

____________________Photophobia (sensitivity to light)

____________________Noise intolerance


____________________Feeling spatially disoriented

____________________Dysequilibrium (balance difficulty)

____________________Staggering gait (clumsy walking; bumping into things)

____________________Dropping things frequently

____________________Difficulty judging distances (e.g. when driving; placing objects on surfaces)

____________________“Not quite seeing” what you are looking at


____________________Hypersomnia (excessive sleeping)

____________________Sleep disturbance: unrefreshing or non-restorative sleep

____________________Sleep disturbance: difficulty falling asleep

____________________Sleep disturbance: difficulty staying asleep (frequent awakenings)

____________________Sleep disturbance: vivid or disturbing dreams or nightmares

____________________Altered sleep/wake schedule (alertness/energy best late at night)


____________________Difficulty with simple calculations (e.g., balancing checkbook)

____________________Word-finding difficulty

____________________Saying the wrong word

____________________Difficulty expressing ideas in words

____________________Difficulty moving your mouth to speak

____________________Slowed speech

____________________Stuttering; stammering

____________________Impaired ability to concentrate

____________________Easily distracted during a task

____________________Difficulty paying attention

____________________Difficulty following a conversation when background noise is present

____________________Losing your train of thought in the middle of a sentence

____________________Difficulty putting tasks or things in proper sequence

____________________Losing track in the middle of a task (remembering what to do next)

____________________Difficulty with short-term memory

____________________Difficulty with long-term memory

____________________Forgetting how to do routine things

____________________Difficulty understanding what you read

____________________Switching left and right

____________________Transposition (reversal) of numbers, words and/or letters when you speak

____________________Transposition (reversal) of numbers, words and/or letters when you write

____________________Difficulty remembering names of objects

____________________Difficulty remembering names of people

____________________Difficulty recognizing faces

____________________Poor judgment

____________________Difficulty making decision

____________________Difficulty following simple written instructions

____________________Difficulty following complicated written instructions

____________________Difficulty following simple oral (spoken) instructions

____________________Difficulty following complicated oral (spoken) instructions

____________________Difficulty integrating information (putting ideas together to form a complete picture or concept)

____________________Difficulty following directions while driving

____________________Becoming lost in familiar locations when driving

____________________Feeling too disoriented to drive


____________________Depressed mood

____________________Suicidal thoughts

____________________Suicide attempt(s)

____________________Feeling worthless

____________________Frequent crying

____________________Feeling helpless and/or hopeless

____________________Inability to enjoy previously enjoyed activities

____________________Increased appetite

____________________Decreased appetite

____________________Anxiety or fear with no obvious cause

____________________Panic attacks

____________________Irritability; overreaction

____________________Rage attacks: anger outbursts with little or no cause

____________________Abrupt, unpredictable mood swings

____________________Phobias (irrational fears)

____________________Personality changes


____________________Rashes or sores

____________________Eczema or psoriasis

____________________Aphthous ulcers (canker sores)

____________________Hair loss

____________________Mitral valve prolapse


____________________Dental problems

____________________Periodontal (gum) disease

© copyright 1999 and 2008 by Katrina H. Berne, Ph.D.,